Provider Demographics
NPI:1073698023
Name:WALTER LAGESTEE INCORPORATED
Entity Type:Organization
Organization Name:WALTER LAGESTEE INCORPORATED
Other - Org Name:WALT'S PHARMACY #5
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:EGAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:708-957-2974
Mailing Address - Street 1:1218 SHEFFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1053
Mailing Address - Country:US
Mailing Address - Phone:219-865-4363
Mailing Address - Fax:219-865-4365
Practice Address - Street 1:1218 SHEFFIELD AVE
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1053
Practice Address - Country:US
Practice Address - Phone:219-865-4363
Practice Address - Fax:219-865-4365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60005711A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200422800Medicaid
IN0917380005Medicare NSC